By Mary Politi, PhD, Associate Professor, Department of Surgery, School of Medicine
At an enrollment event in 2015, I met a woman from a rural county in Missouri who was an outspoken supporter of the Affordable Care Act (ACA). She volunteered her time helping individuals enroll in the ACA marketplace and walking them through the details of plans.
She surprised me with her story. “I was so against Obamacare when it first passed. Government sponsored insurance? Why don’t people just get a job?” she recalled to me. “And then, my husband lost his job. And I lost my job at the same time. What are the chances? Suddenly, we were a family of four supporting our two children with no health insurance.” Her son had a chronic illness, and the thought of him going without medical care hit her deeply, the way it would for most parents worried about their children. “I was so grateful for the ability to purchase insurance without worrying about being denied because of his condition.”
Over the past four open enrollment cycles for health insurance through the ACA coverage options, the Cover Missouri Coalition, Missouri Foundation for Health, Health Literacy Media, and Washington University researchers have worked with individuals, organizations, and policy officials to support health insurance enrollment. The environment in which this activity has taken place is perhaps a microcosm of the U.S., as Missouri’s population is spread over rural, suburban, and urban settings and represents the full spectrum of opinions of “Obamacare.” Our persistent and widespread focus on health insurance education has allowed us to make connections with individuals throughout the state with very different perceptions of healthcare reform. There were many like the woman described above who were initially resistant to the ACA and grew to appreciate its protections. Some who enrolled in plans in the ACA marketplace begged us not to “make it obvious” to their neighbors. Based on these experiences, below are some lessons learned about health insurance enrollment.
Health Insurance Education is Paramount to the Success of Health Insurance Enrollment
Fewer than 25% of uninsured individuals feel they understand basic health insurance terms and concepts, especially about terms like deductibles (the amount you have to pay in full each year before insurance starts sharing costs of healthcare) or out-of-pocket maximums (the highest amount one pays each year, not including premiums or services not covered).
When people have trouble understanding insurance, it can keep them from enrolling, or prevent them from choosing the best plan for their needs and budget.
Some reach out to healthcare providers for guidance, but providers also can be confused about specific aspects of insurance. Health insurance education is paramount to addressing the pervasive health insurance literacy gaps in the population.
At Washington University in St. Louis, we developed a free, web-based decision support tool called Show Me Health Plans4,5 based on principles of health literacy and decision science, evaluated it in research studies, and modified it with user feedback. Show Me Health Plans provides plain language health insurance education, asks consumers what insurance features matter most to them, and calculates how much consumers might spend on health insurance plus healthcare costs in any given year across plans in the ACA marketplace. It also helps users determine their eligibility for Medicaid, and/or a bridge program called Gateway to Health for those in the St. Louis region who would have qualified for Medicaid had Missouri expanded the Medicaid program. Those who used Show Me Health Plans, compared to those who used healthcare.gov to shop for plans, had higher insurance knowledge and more confidence making plan choices. They were also more likely to choose plans that matched their health needs and preferences.
In a qualitative study, Certified Application Counselors (CACs) from urban, suburban, and rural areas of the state suggested that tools such as Show Me Health Plans might better prepare individuals for meetings with in-person support:
“…if there were interactive tools like this there that they could learn about health insurance, they could learn about these things, I think it may help them come in more informed and even asking better questions when they get in front of the navigator or someone else.”
“Education and literacy is very most important. ‘Cause we serve people who had insurance all their life and still never understand.”
Personalized Cost Calculators Are Critical Parts of Health Insurance Education
A key component of health insurance education is the use of cost calculators to help individuals estimate their annual healthcare expenses, rather than focusing on monthly premiums. Enrollment facilitators work with individuals to estimate their costs across plans. In our web-based tool, Show Me Health Plans calculates these costs across plans by using Medical Expenditure Panel Survey (MEPS) data from the Agency for Healthcare Research and Quality, nationally representative data of healthcare expenses across age groups, genders, and common health conditions. It also adjusts for the potential risk of an unusually costly year; for example, older individuals or those with multiple chronic conditions have a higher chance of spending more than average, compared to those who are younger and healthier when enrolling.
CACs suggested that cost calculations are the most difficult for consumers. For example, the difference between copayments and coinsurance can leave some worried about being responsible unknown dollar amounts:
“People will say, “…How can I find a plan that eliminates that high expense?” People who need a lot of care…may want to look for a plan without co-insurance…Because…it fluctuates whenever you go. If you’re looking for something that’s more concise, then a co-pay would be better.”
In-Person or Phone Based Support Can Reduce Consumer Anxiety
Despite the promise of online tools or mobile apps for some consumers, accessible in-person or phone-based support may need to supplement the function of online support. In our qualitative study, CACs often commented that older adults or those with lower computer literacy might be intimidated by online tools and could prefer to seek support in-person or by phone. Some suggested that even younger individuals might find online education cumbersome:
“I think people might think of it as just another unnecessary chore…They might perceive it that way. Um, like, “Oh, I’m getting homework. I wanna get my health insurance and they’re giving me homework!” Um, it depends on how – I guess – how you package it.”
Others described that space limitations at enrollment centers or social service organizations could preclude individuals from completing online tools:
“We just don’t have the capability of leaving somebody in a room alone with computers, cause we just don’t have the space.”
Counselors suggested that many individuals seek reassurance about selecting a plan, and counselors can address consumers’ anxiety in a way that online tools cannot. As one counselor commented:
“I always tell people, when they look super stressed…it’s an important choice…but it’s not the health insurance plan you’re going to have for the next ten years…reminding people that you can choose another plan during open enrollment is important.”
Health Insurance Reform That Adds Burden to Consumers May Fail to Provide Adequate Coverage or Cost Reductions
Given the overwhelming details inherent to insurance choice, policy solutions that continue to burden consumers may fail to address population-level enrollment needs. For example, some health reform proposals encourage the use of high deductible health plans with health savings accounts as a type of security in the case of unexpectedly large medical bills. Health savings accounts allow individuals to set aside pre-tax dollars to use for qualified medical expenses. Some believe they will lower healthcare spending overall. However, many individuals enrolling in the insurance marketplace—especially in states like Missouri which did not expand Medicaid—do not have the financial reserves to invest in these accounts. In addition, these plans require individuals to calculate even more complex risk and cost information than focusing on health insurance details alone.
Medicaid Expansion is Critical to Facilitating Coverage, Especially Among High-Risk Individuals
Medicaid expansion was a key component of the ACA that was designed to allow individuals with incomes at or below 138% of the Federal Poverty Level (FPL) to enroll in Medicaid. Medicaid expansion saves lives and is cost-effective for society. However, 19 states—including Missouri—selected not to expand Medicaid eligibility. In Missouri, citizens must make 18% of the FPL to qualify for Medicaid. Some individuals such as males with no dependents might never qualify for Medicaid, no matter how low their income.
States that did not expand Medicaid now have the highest uninsured rates in the country, ranging from 13%-16%, compared to 9% nationally. The Marketplace was set up to provide subsidies and cost-sharing reductions to those making between 138% and 400% of the FPL, assuming that that states would expand Medicaid. In Missouri, that leaves approximately 96,000 people in the “coverage gap” where the marketplace is prohibitively expensive, but Medicaid is not an option.
In addition to burdening low-income consumers who fall in this coverage gap, some CACs described the challenges reaching people who fluidly roll in and out of Medicaid eligibility. These individuals whose income or family status changes could be covered outside of open enrollment, but they might not know about this exception:
Anybody who…loses their job, or gets a new job, and isn’t in the Medicaid gap anymore…those are populations that are a lot harder to catch because they don’t know that [they qualify for a special enrollment period].”
The current state of health insurance reform suggests that far fewer federal resources will be provided to facilitate consumer education and outreach about the ACA marketplace and beyond. Consumer engagement will be critical; stories such as the enrollment facilitator from rural MO described above can help others learn about the benefits of safety net programs. Strategies that help reduce consumer anxiety and the potential stigma associated with “Obamacare,” combined with grass roots outreach, may address some of these barriers.
Regardless of the political nature of this decision, our work suggests that health insurance education and support will be of utmost importance for years to come.
A large body of evidence continues to demonstrate that health insurance access improves health outcomes, including chronic disease prevention, illness management, medication adherence, mental health, and mortality. As states across the country prepare for open enrollment in 2018, with limited federal resources and the potential for cuts to subsidies and cost-sharing, focusing on disseminating application checklists and free, accessible, evidence-tested consumer support can better engage consumers through the process of selecting insurance to improve access to care and numerous, widespread health outcomes.
This post is part of the “Transforming Healthcare in Missouri” series of the Institute for Public Health’s blog. Subscribe to email updates or follow us on Twitter and Facebook to receive notifications about our latest blog posts.Tags: decision support, enrollment, health insurance, healthcare, Transforming Healthcare in Missouri